Dissociative Identity Disorder - Specialists and Information

Dissociative Identity Disorder (DID) is the most severe form of a dissociative disorder. It is also known as “multiple personality disorder.”

The disorder includes all the key elements of a dissociative disorder.

The following symptoms may occur as part of the condition:

• Dissociative amnesia (memory loss)
• Fugue states (sudden, unexpected, and aimless running away for no apparent reason)
• Severe depersonalization (i.e., the self and one’s own body are perceived as alien and unreal)
• Derealization (i.e., the environment is perceived as alien)

In dissociative identity disorder (formerly multiple personality disorder), two or more identities coexist within the same person @ von Lieres /AdobeStock

Dissociative Identity Disorder as a Chronic Disorder

Dissociative identity disorder is a chronic disorder.

According to the DSM-IV and ICD-10 diagnostic classification systems, the dissociative disorders described are typically temporary.

If dissociative identity disorder is not treated appropriately, it can become permanent. Over the course of a person’s life, it can manifest in various forms.

Existence of Multiple Subpersonalities

Multiple personality disorder is one of the most unusual mental conditions. The affected individual splits into several seemingly separate and independent subpersonalities.

These subpersonalities take turns determining the person’s behavior. This seems incredibly fascinating to some people and causes others to express vehement outrage.

The existence of such subpersonalities within an individual challenges generally accepted assumptions about the unity of personality and the structure of consciousness.

Difficulty in Classifying Symptoms

Furthermore, almost all symptoms characteristic of many other psychiatric disorders can occur. Classifying psychopathological syndromes and comorbid (additional) mental disorders can therefore be very difficult.

In dissociative identity disorder, a person’s sense of self splits into distinct personalities, each of which then leads a life of its own @ Lazy_Bear /AdobeStock

The history of dissociative identity disorder runs parallel to that of modern psychiatry.

Jean-Martin Charcot (1825–1893) and his colleagues Babinski (1857–1932), Bernheim (1840–1919), and Janet (1859–1947) conducted intensive research on the phenomenon.

They made dissociative phenomena in general—and “multiple personality disorder” in particular—a central focus of their theories.

A similar development took place in the United States. The leading figures, William James (1842–1910) and Morton Prince (1854–1929), had personal experience with DID patients.

Based on these experiences, they explored the nature of consciousness and the organization of the psyche.

Even Freud, early in his career, explored the nature of dual consciousness (e.g., the case of Anna O. in Breuer). Later, however, Freud developed his psychodynamic theory. In short, this theory focuses not on dissociation but on repression and other unconscious mechanisms.

Pierre Janet coined the term “dissociation” to describe the disintegration and fragmentation of consciousness. He described a diathesis-stress model that remains valid to this day.

It serves as the basis for current theories of dissociation, such as the theory of structural dissociation.

Dissociative Identity Disorder was first included in a psychiatric classification system in 1980 (DSM-III, APA 1980). In 1991, it was also included in the ICD-10.

According to the ICD-10, dissociative identity disorder is a rare disorder. It has a prevalence similar to that of borderline personality disorder.

Estimates suggest that 1–3 percent of the general population is affected. Among patients receiving psychiatric treatment, 5 percent are affected by dissociative identity disorder. Dissociative identity disorder is not uncommon.

Women appear to be affected by dissociative identity disorder much more frequently than men.

Patients are often misdiagnosed. Doctors either fail to recognize the disorder or make an incorrect diagnosis.

This likely applies to other dissociative disorders as well. As a result, patients often do not receive psychotherapeutic treatment—or they do not benefit from it.

Early diagnosis makes disorder-specific psychotherapy possible. This can have a positive impact on the course of dissociative identity disorder.

Various studies have already attempted to determine why people suffer from dissociative identity disorder. These studies reveal significant physiological differences between DID patients and control subjects.

These differences manifest themselves in a variety of behaviors.

These include, among others:

• Visual acuity
• Reactions to medications
• Allergies
• Skin conductance
• Plasma glucose levels in patients with diabetes mellitus
• Heart rate
• Blood pressure
• Galvanic skin conductance
• Muscle tension
• Lateralization (distribution of processes to the right and left hemispheres of the brain)
• Immune functions
• EEG patterns and evoked potential patterns
• Activation in functional magnetic resonance imaging (fMRI)
• Brain activation and
• Regional cerebral blood flow measured using single-photon emission computed tomography (SPECT) and positron emission tomography (PET)

Overall, DIS patients exhibit greater physiological variability between their identities than the simulated identities in the control subjects.

This variability is greater than the type of reproducible differences found between different individuals.

Studies show psychobiological differences between the identities when they listened to a trauma script that reminded them of only one identity.

These differences included:

• Subjective sensorimotor and emotional reactions 
• Psychophysiological reactions such as heart rate and blood pressure, as well as 
• patterns of regional cerebral blood flow (measured using positron emission tomography)

However, these psychobiological differences do not exist when each of the alternative identities alternately hears a neutral, non-traumatic, autobiographical memory script.

Traumatic childhood experiences

Furthermore, there is a hypothesis that shifting identities arise from traumatic childhood experiences.

Traumatic experiences before the age of five make it difficult for children to develop a unified sense of self.

These difficulties often occur in connection with relationship or attachment breakdowns. They can be precursors and predictors of abuse and the development of dissociative processing.

Severe and prolonged traumatic experiences can lead to the development of distinct, personified behavioral states (i.e., fragmented personality parts) in the child.

These result in the encapsulation of memories, emotions, beliefs, and behaviors. They have a major influence on the child’s overall development.

A secondary structuring of these distinct behavioral states takes place over a longer period of time through various developmental and symbolic mechanisms.

This ultimately results in the character traits of the specific personality parts.

These parts may continue to develop in terms of number, complexity, and the sense of separateness as the child grows older.

Dissociative identity disorder develops during childhood. It rarely results from trauma experienced in adulthood.

Instead of the fragmentation of a core identity, the development of multiple personalities

The theory of “structural dissociation of the personality” attempts to provide a unified theory of dissociation that incorporates dissociative identity disorder.

This theory posits that dissociation is the result of a faulty integration of the personality’s systems of ideas and functions.

After the personality has experienced traumatic events, it splits into a normal and an emotional part.

The normal part of the personality is responsible for everyday functioning, while the emotional part is responsible for defense mechanisms.

Defense refers to the psychobiological functions of survival that occur in response to a life-threatening situation. 

These include:

• Fight
• flight, and 
• Freezing

According to current assumptions, chronic trauma and/or neglect lead to secondary structural dissociations.

Etiological models suggest that dissociative identity disorder does not arise from a fractured or damaged core personality.

The basis of dissociative identity disorder is therefore a failure of normal developmental integration. This is usually caused by overwhelming experiences or by disrupted caregiver-child interactions during early developmental periods.

These include:

• neglect and
• lack of responsiveness

This leads some children to develop relatively distinct, personified behavioral states that eventually become DID personality parts.

Controversy over the causes of dissociative identity disorder

Some authors believe that psychologists create dissociative identity disorder because they believe in it and influence their patients.

According to this sociocognitive model, dissociative identity disorder is merely a socially constructed condition consisting of the following elements:

• Cues from the psychologist (e.g., suggestive questions about the existence of possible shifting identities)
• Media influence (e.g., film and television portrayals of dissociative identity disorder) and
• Broader sociocultural expectations

Proponents of the sociocognitive model believe that the book and film *Sybil* played a role in the 1970s.

However, studies show that suggestion, contagion, or hypnosis cannot cause dissociative identity disorder. Nor is it possible to sustain it over a prolonged period.

Although the American Psychiatric Association and the World Health Organization have characterized dissociative disorders, they have not fully described their characteristics.

The key feature, however, is a disruption of the normally integrated functions of consciousness, memory, identity, or perception.

The extent to which the definition of dissociation is broad or narrow remains a subject of ongoing debate.

Putnam (2003) described the dissociative process as a normal mechanism for coping with traumatic experiences.

However, this process can develop into a dysfunctional or pathological one. This results in changes in consciousness characterized by a sense of detachment from the self and/or the environment.

Negative dissociative vs. positive dissociative symptoms

There are negative dissociative and positive dissociative symptoms.

Negative dissociative symptoms involve a reduction or suspension of psychological processes.

Examples include:

• Memory loss
• Depersonalization associated with a split between the experiencing and observing parts of the personality
• Loss of personality traits

Positive dissociative symptoms involve the generation or exaggeration of a psychological process.

Examples include:

• Hearing voices, fabricated emotions, thoughts, and ideas
• Reliving traumatic events, e.g., specific visual and auditory perceptions, emotions, and ideas
• Shifting between different dissociated personality parts
• A disorder characterized by the relatively long-term activation of a psychotic dissociated subpersonality

The definition by Dell and O’Neil (2009) elaborates on the central concept of disruption in the DSM-IV-TR: “Pathological dissociation manifests itself essentially as a partial or complete disruption of the integration of a person’s mental processes.

In particular, dissociation can interrupt, alter, or intrude upon consciousness and experience.

The following may be affected:

• Body
• Mind
• Capacity to act
• Thoughts
• Belief
• Knowledge
• Recognition
• Remembering
• Feeling
• Want
• Speaking
• Act
• See
• Hearing
• Smell
• Taste
• Touch

Those affected typically experience these disruptions as alarming, autonomic intrusions into their usual responses or functioning.

The most common dissociative intrusions include:

• hearing voices
• Depersonalization
• derealization “imposed” thoughts
• Urges
• desires
• Emotions and actions

Dissociative processes manifest in various forms, many of which are not pathological. These occur automatically and reflexively. They are part of a brief, temporary, normal biological response that disappears as soon as the danger has passed.

The relationship between the dissociative reaction and the intensity and nature of the dissociation remains unclear.

According to estimates, 1–3 percent of the general population is affected @ Natalia Klenova /AdobeStock

The primary reason for the difficulties in diagnosing dissociative identity disorder is insufficient training on the subject.

Although dissociative identity disorder is a relatively common condition, only 6 percent of those affected disclose their condition publicly.

Instead of exhibiting the various identities, typical DID patients display dissociative and other trauma-related symptoms.

These include, for example:

• Depressive symptoms
• Anxiety symptoms
• Symptoms of substance dependence
• Eating disorders

The latter symptoms often lead doctors to diagnose only this condition.

Assessing Dissociative Symptoms

Unfortunately, standard interviews and methods for psychopathological assessment often do not include questions about dissociative and post-traumatic symptoms. Past psychological traumas are also not addressed.

DIS patients rarely disclose information about dissociative symptoms. Therefore, only targeted questions about dissociative symptoms can ensure an accurate diagnosis.

The basic prerequisite for diagnosing dissociative identity disorder is therefore actively inquiring about dissociative symptoms. The open-ended clinical interview should be structured and supplemented with screening questionnaires. Both should assess the (absence of) dissociative symptoms and disorders.

When using screening instruments (questionnaires), it is important to note that high scores alone are not sufficient for a diagnosis of a dissociative disorder. Further differential diagnostic evaluation through clinical interviews or structured interviews is necessary in such cases.

In practice, screening instruments are used to assess the nature and extent of dissociative symptoms. It is also possible to engage a person in a conversation about their experiences by asking targeted questions.

Questionnaire on Dissociative Symptoms (FDS)

The most commonly used screening instrument is the Dissociative Symptoms Questionnaire (DSQ). The DSQ consists of 44 items and takes about 20 minutes to complete.

Respondents rate on a scale from 0 to 100 percent how often specific examples of dissociative experiences occur in their daily lives.

The items fall under the subscales of Absorption, Derealization/Depersonalization, Amnesia, and Conversion.

Scoring is based on the calculation of the mean. The resulting value is called the FDS.

Clinically relevant are all total scores (overall means) above 12, which indicate mild dissociative symptoms.

For total scores above 25, suspicion of a dissociative disorder should be clarified through a structured interview.

SKID-D (Structured Clinical Interview for Dissociative Disorders according to the DSM)

In German-speaking countries, the structured clinical interview is the method of choice. The SKID-D enables diagnosis based on operationalized criteria.

There are 277 items that, within the framework of a semi-structured interview, provide information regarding the nature and severity of core dissociative symptoms.

In addition to the responses, observed dissociative symptoms are also included in the evaluation.

Examples of observed symptoms include:

• Amnesia for previous questions
• Stuporous states
• Noticeable changes in behavior and
• Other nonverbal abnormalities observed during the interview

Diagnostic criteria for dissociative identity disorder according to DSM-IV

The Diagnostic and Statistical Manual lists the following diagnostic criteria for dissociative identity disorder:

• The presence of two or more distinct identities or personality states.
• At least two of these identities or personality states repeatedly take control of the person’s behavior.
• An inability to recall important personal information. This information is too extensive to be attributed to simple forgetfulness.
• The disorder is not attributable to the effects of a substance (such as blackouts or disorganized behavior during alcohol intoxication).

Note: In children, the symptoms cannot be explained by imaginary playmates or other fantasy play.

Research Discourse on the Definition and Criteria of the Disorder

Unfortunately, the description of the disorder in ICD-10 under F44.81 differs strikingly from this criteria-based classification.

It contains a collection of descriptions and assumptions that only partially align with the information in the DSM-IV.

Consequently, experts have been discussing the DSM-IV diagnostic criteria for dissociative identity disorder in recent years.

Dell (2009) suggests that the lack of specific clinical symptoms greatly reduces the utility of the criteria for non-specialist clinicians. A compilation of commonly occurring dissociative symptoms would better capture the typical clinical presentation of DID patients.

Others argue that the current criteria are sufficient. Still others propose classifying dissociative disorders as trauma-related disorders.

Treatment for dissociative identity disorder is psychotherapeutic. The first step is to establish a trusting therapeutic relationship based on safety, meaning, and respect.

The goals are:

• Promoting affect differentiation and regulation
• Developing personal responsibility, self-efficacy, and self-control

This leads to long-term psychotherapy aimed at resolving the original trauma and establishing a unified sense of self.

For dissociative identity disorder, psychotherapy is generally the treatment of choice @ Photographee.eu /AdobeStock

The updated ISSTD treatment guidelines recommend an eclectic treatment approach that incorporates psychodynamic, cognitive-behavioral, hypnotherapeutic, and trauma-informed methods.

A phase-oriented approach that first focuses on the patient’s safety and stability has proven effective for trauma-related disorders.

Subsequently, the focus shifts specifically to processing the traumatic material. In addition, disorder-specific techniques are used that aim to actively incorporate the dissociated self-states into therapy. This allows the integration process to take place, leading to the development of a coherent self.

Long-term psychotherapy for the treatment of dissociative identity disorder

The treatment of choice is individualized long-term outpatient psychotherapy, consisting of up to two hours per week over several years.

Combined treatment approaches involving outpatient and inpatient interval therapy have also proven clinically effective.

There is also positive evidence regarding structured group programs in combination with individual therapy. This represents a more efficient and cost-effective alternative to long-term individual psychotherapy.

Medication for dissociative identity disorder

Medications play a role in the treatment of dissociative identity disorder only when treating comorbid disorders.

When comorbid disorders are present, they should be treated according to the relevant guidelines in a disorder-specific manner. This also applies to pharmacological treatment.

For example, antidepressants are used to treat depressive symptoms, depending on their severity.

To date, the symptoms of dissociative identity disorder cannot be treated with medication. On a trial basis, doctors occasionally use naloxone to interrupt dissociative symptoms; however, this has not been shown to produce lasting success.